How do you respond to a payer audit questioning code assignment?

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Responding to a Payer Audit Questioning Code Assignment

1. Review the Audit Request Carefully:
   Understand exactly which claims and codes are under review and what the payer’s concerns are.

2. Gather Documentation:
   Collect all relevant medical records, physician notes, test results, and any other clinical documentation supporting the services billed.

3. Verify Code Accuracy:
   Double-check that the questioned codes accurately reflect the documented services and meet official coding guidelines (CPT, ICD-10, HCPCS).

4. Consult Coding Guidelines & Policies:
   Reference authoritative sources like CMS guidelines, CPT manuals, and any applicable Local Coverage Determinations (LCDs) to justify the code choices.

5. Prepare a Clear, Professional Response:

   • Summarize your findings.

   • Attach supporting documentation.

   • Explain how the codes comply with coding rules and payer policies.

   • If errors are identified, acknowledge and describe corrective actions taken.

6. Maintain Compliance and Transparency:
   Be honest and thorough. Providing clear, well-documented evidence helps resolve audits favorably and builds payer trust.

7. Follow Up and Track:
   After submission, track the audit status. Be ready to provide additional info or participate in discussions if requested.

Summary:
Respond promptly by reviewing the audit, compiling thorough documentation, justifying code choices with guidelines, and communicating clearly and professionally. This approach helps defend your coding decisions and ensures audit resolution.

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